Rhode Island Code of Regulations
Title 216 - Department of health
Chapter 10 - Public Health Administration
Subchapter 10 - Registries
Part 5 - Rhode Island All-Payer Claims Database
Section 216-RICR-10-10-5.2 - Definitions

1. "Alternative payment model (APM) file" means a data file composed of payments made to providers outside of the traditional fee-for-service (FFS) model. For example, alternative payment models may include, but are not limited to, pay for performance/penalty, shared savings/shared risk, global budget, limited budget, and capitation. Alternative payment models may also include FFS payments which are settled or reconciled under a certain alternative payment model category. The APM file also includes all payments made to providers under the traditional FFS model. In accordance with R.I. Gen. Laws § 23-17.17-9(e), the APM file shall not include trade secrets as defined in R.I. Gen. Laws § 6-41-1(4).

2. "Applicant" means an individual or organization that requests health care claims data set and information in accordance with the procedures and requirements instituted by the Department pursuant to this Part.

3. "Data aggregator" means a vendor selected by the Director that has a contract to act on behalf of the Department to collect and process health care claims data on behalf of the Director.

4. "Department" means the Rhode Island Department of Health.

5. "Dental claims file" means a data file composed of service-level remittance information for all submitted and non-denied adjudicated claims for each billed dental service, including but not limited to Member Encrypted Unique Identifier, provider information, charge/payment information, and dental procedure codes.

6. "Director" means the Director of the Department of Health or his or her duly authorized designee.

7. "Direct personal identifier" means any information, as to a Member, other than case or code numbers used to create anonymous or encrypted data, that plainly discloses the identity of an individual, including:

8. "Disclosure" means the release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information.

9. "Encrypted unique identifier" means a code or other means of record identification to allow each Patient, Member or enrollee to be tracked across the data set, including across payers and over time, without revealing Direct Personal Identifiers. Encrypted Unique Identifiers are assigned to each Patient, Member or enrollee in order that all Direct Personal Identifiers can be removed from the data when data is submitted. Using the Encrypted Unique Identifier, all records relating to a Patient, Member or enrollee can be linked for analytical, public reporting and research purposes without identifying the Patient, Member or enrollee.

10. "Encrypted unique identifier vendor" means a vendor selected and approved by the Director to collect demographic data only from Insurers, assign an Encrypted Unique Identifier to each Patient, Member, or enrollee, and transmit that identifier to the Insurer.

11. "Hashing" means a one (1) way method by which the true value of data has been transformed (through the conversion of the information into an unrecognizable string of characters) in order to prevent the identification of persons or groups. True value of hashed elements is deliberately non-recoverable by any recipient, including the Data Aggregator.

12. "Health benefit plan" means a policy, contract, certificate or agreement entered into, or offered by an Insurer to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

13. "Health care claims data set" means a collection of individual claims-based data files, including Dental Claims File, Medical Claims Files, Pharmacy Claims Files, Member Eligibility Files and Provider Files, whether in electronic or manual form.

14. "Health care facility" means the same meaning as contained in R.I. Gen. Laws Chapter 23-17 and the Regulations promulgated pursuant to that Chapter.

15. "Health care provider" means any person or entity licensed to provide or lawfully providing health care services, including, but not limited to, a physician, hospital, intermediate care facility or other Health Care Facility, dentist, nurse, optometrist, podiatrist, physical therapist, psychiatric social worker, pharmacist or psychologist, and any officer, employee, or agent of that provider acting in the course and scope of his or her employment or agency related to or supportive of health care services.

16. "HIPAA" means the Health Insurance Portability and Accountability Act of 1996, as amended, and its implementing Regulations (45 C.F.R. Parts 160 through 164).

17. "Insurer" means any entity subject to the insurance laws and Regulations of Rhode Island, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services and/or dental services, including, without limitation, an insurance company offering accident and sickness insurance, a health maintenance organization, as defined by R.I. Gen. Laws § 27-41-1, a nonprofit hospital or medical service corporation, as defined by R.I. Gen. Laws Chapters 27-19 and 27-20, or any other entity providing a plan of health insurance or health benefits. For the purpose of this Part, a third (3rd) party Payer, third (3rd) party Administrator, Pharmacy Benefits Manager or Medicare or Medicaid health plan sponsor is also deemed to be an Insurer.

18. "Medical claims file" means all submitted and non-denied adjudicated claims for each billed service paid by an Insurer as defined in § 5.2(A)(16) of this Part on behalf of a Member as defined in § 5.2(A)(18) of this Part regardless of where the service was provided. This data file includes but is not limited to service level remittance information including, but not limited to, Member Encrypted Unique Identifier, provider information, charge/payment information, and clinical diagnosis/procedure codes as described further in the RIAPCD Technical Specification Manual.

19. "Member" means a Rhode Island resident who is a Subscriber and any spouse or dependent who is covered by the Subscriber's policy under contract with an Insurer. The term also includes Members of a small employer health insurance plan as defined by R.I. Gen Laws § 27-50-3 regardless of the State of residency of the Member.

20. "Member eligibility file" means a data file composed of demographic information for each individual Member eligible for medical or pharmacy benefits as specified in the RIAPCD Technical Specification Manual, for one (1) or more days of coverage at any time during the reporting month.

21. "Patient" means any person in the data set that is the subject of the activities of the claim submitted to and/or paid by the Insurer or covered by the health benefits plan.

22. "Personal health information" means information, as to a Member, about health status or provision of healthcare, including demographic information, medical history, test and laboratory results, insurance information and other data that a healthcare professional collects to identify an individual and determine appropriate care.

23. "Pharmacy benefits manager" or "PBM" means any person or entity that develops or manages pharmacy benefits, pharmacy network contracts, or the pharmacy benefit bid process pursuant to a contract held with an Insurer for the provision of such services.

24. "Pharmacy claims file" means a data file composed of service-level remittance information including, but not limited to, Member demographics, provider information, charge/payment information, and national drug codes from all submitted and non-denied adjudicated claims for each prescription filled.

25. "Provider file" means a data file composed of provider information for each provider included on a medical, pharmacy or dental claim submitted during the reporting period, regardless of the type of provider or location where the services were provided, as specified in the RIAPCD Technical Specification Manual.

26. "Rhode Island all-payer claims database" or "RIAPCD" means a health care quality and value database for the collection, management and reporting of eligibility, claims and provider data submitted pursuant to R.I. Gen. Laws Chapter 23-17.17.

27. "RIAPCD technical specification manual" means the document entitled RIAPCD Technical Specification Manual Version 1.6 issued by the Department, or its contracted agent, that sets forth the required data file format, record specifications, data elements, definitions, code tables and edit specifications.

28. "Subscriber" means the individual responsible for payment of premiums to an Insurer or whose employment is the basis for eligibility for Membership in a Health Benefit Plan.

29. "Third-party administrator" or "TPA" means any person with a certificate of authority, issued pursuant to R.I. Gen Laws § 27-20.7-12, who directly or indirectly solicits or effects coverage of, underwrites, collects charges or premiums from, or adjusts or settles claims on Members, pursuant to R.I. Gen. Laws § 27-20.7-2(1).

30. "Third-party payer" means a State agency that pays for health care services, or an insurer, carrier, including a carrier that provides only administrative services for plan sponsors, nonprofit hospital, medical services organization, or managed care organization licensed in Rhode Island.

31. "User" means any person who the Department has authorized to access and use data from the Rhode Island All-Payer Claims Database.